“We will change the world, starting from the very beginning.” Building Babies Brains. Criança Feliz, Brazil’s audacious plan to fight poverty – Jenny Anderson * Advancing Early Childhood Development: from Science to Scale – The Lancet * A groundbreaking study offers undeniable proof that the fight against inequality starts with moms – Jenny Anderson.

“How can we most dramatically improve the quality of life for our citizens, their health, their education? The answer to that question lies in starting at the beginning, at pregnancy, and in the first few years of a child’s life.” Osmar Terra

Decades of groundbreaking research shows that the love and sense of safety experienced by a baby directly impacts how the child’s brain is wired. Adversity, especially persistent, stress-triggering adversity like neglect and abuse, hampers that development, and can result in poorer health, educational attainment, and early death.

“Children who experience profound neglect early in life, if you don’t reverse that by the age of two, the chance they will end up with poor development outcomes is high. The strongest buffer to protect against that? A parent, or caring adult.” Charles Nelson

The best investment a policymaker can make is in the earliest years of childhood, because that’s when intervention has the highest payoffs. Strong biological, psychosocial, and economic arguments exist for intervening as early as possible, starting from and even before conception, to promote, protect, and support children’s development.

Studies have found that children whose mothers received coaching made significant developmental gains, and not just in the short term. Twenty-two years later, the kids from one group who had received those home visits as young children not only had higher scores on tests of reading, math, and general knowledge, they had stayed in school longer. They were less likely to exhibit violent behavior, less likely to experience depression, and had better social skills. They also earned 25% more on average than a control group of kids whose mothers had not received the coaching.

Osmar Terra is a tall man with a deep voice and an easy laugh, one that disguises the scale of his ambition to transform Brazilian society. A federal representative for nearly two decades, he is the driving force behind the world’s biggest experiment to prove that teaching poor parents how to love and nurture their infants will dramatically influence what kind of adults they become, and give Brazil its best shot at changing its current trajectory of violence, inequality, and poverty.

Terra, aged 68, first became obsessed with the question of how humans develop nearly 30 years ago. As a cardiologist in the 1990s, he would read endless research papers about the neuroscience of early childhood. When he entered politics, becoming mayor of Santa Rosa in Rio Grande do Sul in 1992, he continued to grapple with the question, even studying for a master’s degree in neuroscience. The science, he believed, should lead to smart policy. As a doctor and a manager, a mayor and a state health secretary, he was always trying to figure out how to to tackle poverty head-on. “In every single activity I always ask myself, ‘What is the public policy that can be more transformative?’” he says. “How can we most dramatically improve the quality of life for our citizens, their health, their education?”

The answer to that question, he came to realize, lay in starting at the beginning, at pregnancy, and in the first few years of a Child’s life.

Decades of groundbreaking research shows that the love and sense of safety experienced by a baby directly impacts how the child’s brain is wired. Adversity, especially persistent, stress-triggering adversity like neglect and abuse, hampers that development, and can result in poorer health, educational attainment, and early death. While science underpins his mission, Terra’s palpable passion for the topic and his skill at politicking eventually led him to create Criança Feliz, a highly ambitious parent coaching program he helped launch in 2017 to try and reach four million pregnant women and children by 2020.

Under Criança Feliz, an army of trained social workers, a sort of national baby corps, are dispatched to the poorest corners of Brazil. Traveling by boat, sometimes battling crocodiles and floods, by foot, by car, by truck and by bus, these social workers go to people’s homes to show them how to play, sing, and show affection to their infants and young children. They explain to parents why this matters:

Emotional safety underpins cognitive growth. Intelligence is not fixed, but formed through experience.

Parent coaching, and specifically, home visiting, is not new. The most famous study, which took place in Jamaica in the 1970s, showed that well trained home visitors supporting poor mothers with weekly visits for two years led to big improvements in children’s cognition, behavior, and future earnings. One group of infants in that program who received coaching in their earliest years earned 25% more than a control group more than 20 years later.

But Brazil’s ambition is audacious. No city or country has ever attempted to reach so many people in such a short amount of time. (The largest program doing this now is probably in Peru, reaching about 100,000 families; Criança Feliz is already reaching 300,000.) “They are raising the bar for what is possible nationally,” says Jan Sanderson, the former deputy minister of children from Manitoba, Canada, who is an expert in home visiting and recently traveled to observe the program.

Just how Brazil, a massive country with endemic poverty and grating inequality, came to embrace parent coaching as the next frontier in combating poverty is a story of Terra’s political will, the strategic savvy of a few foundations, the pivotal role of a Harvard program, and the compassion of a growing group of unlikely allies, from communists to far-right wing politicians. Talking to lawmakers in Brazil can feel like wandering around a neuroscience convention: One senator from the south can’t stop talking about working memory, while a mayor from the northern town of Boa Vista in Roirama state is fixated on synapse connection.

At least 68 senators and congresspeople, judges, and mayors have converted to the cause, becoming evangelical in their focus on early childhood development.

“I believe that this is the solution, not only for Brazil, but for any country in the world in terms of security, public security, education, and health care,” says Iosé Medeiros, a senator from the state of Mato Grosso who heads the parliamentary committee on early childhood development. “It’s a cheap solution.”

Terra’s claims are more dramatic. “We will change the world, starting from the very beginning.”

Those words are hardly surprising coming from the man whom Ely Harasawa, Criança Feliz’s director, calls the program’s “godfather.” But the devil, of course, is in the details, and in Terra and his allies’ ability to steer a course through some rather treacherous political terrain.

Criança Feliz in action

On a hot day in May, Adriana Miranda, a 22-year-old accounting student, visits Gabriela Carolina Herrera Campero, also 22, who is 36 weeks pregnant with her third child. Campero arrived in Brazil less than a year ago from Venezuela, fleeing with her husband and two children from that country’s financial collapse and ensuing chaos. She lives in Boa Vista, a city in the north of Brazil where 10% of the population are estimated to be refugees.

The two women greet each other warmly and start chatting, in spite of the fact that Miranda is speaking in Portuguese and Campero in Spanish. They sit together on plastic chairs on a concrete patio as Miranda goes through a checklist of questions about the pregnancy. Has Campero been to her prenatal visits? (Yes.) How is she feeling? (Hot.) Is she drinking enough water? (Yes.) And walking? (When it’s not too hot.) Is she depressed or anxious? (No, but worried, yes.) Does she feel supported by her husband? (Yes.) How is she sleeping and what kinds of foods is she eating? (She’s not sleeping well because she always has to pee, and she is eating a lot of fruit.)

Miranda moves on to talking with Campero about attachment, how to create a strong bond with a baby in utero, and also once the baby is born. Does she know that at five months, the baby can hear her and that her voice will provide comfort to the baby when it is born?

“It’s important the baby feel the love we are transmitting. When he is in distress, he will know your voice and it will calm him,” says Miranda.

It’s a topic they have discussed before. Campero is eager to show what she has learned about the baby. (A part of the program requires that visitors check for knowledge.) “It has five senses, and if I talk, he will know my voice,” she says. “The baby will develop more.” They discuss the importance of cuddling a baby and being patient.

Having a baby in the best of circumstances can be challenging. As an impoverished refugee, in a new country, it can be utterly overwhelming.

I ask Campero, in Spanish, whether the program has been helpful. After all, she already has two kids. Doesn’t she know what to expect? She starts to cry. “They have helped me emotionally,” she says. “She has taught me so many things I didn’t know.” For example, she didn’t know to read to a baby, or that her baby could hear her in utero. Her son used to hit her belly; he now sings songs to the baby because she explained to him what she learned from Miranda. “I feel supported,” she tells me.

Many people, rich and poor alike, have no idea what infants are capable of. Psychologists and neuroscientists believe they are creative geniuses, able to process information in far more sophisticated ways than we ever knew. But for that genius to show itself, the baby needs to feel safe and loved and to have attention.

Medeiros explains how he viewed parenting before he went to the Harvard program.

”I raised my kids as if I were taking care of a plant,” he recalls. “You give them food, you take care of them.” He says he did the best he could, but “I did not have all this information. If I had encouraged them, stimulated them more, I would have been able to contribute much more to their development.”

He is hardly the exception. A 2012 nationally representative survey in Brazil asked mothers, 5200 of whom were college educated, what things were most important for the development of their children up to three years of age. Only 19% mentioned playing and walking, 18% said receiving attention from adults, and 12% picked receiving affection. “So playing, talking to the child, attachment, it’s not important for more than 80% of the people who are interviewed,” says Harasawa, the director of Criança Feliz.

Criança Feliz is part of Brazil’s welfare program for its poorest citizens, called Bolsa Familia. Started 15 years ago, the welfare program is rooted in a cash transfer system that makes payments contingent on kids getting vaccines and staying in school, and pregnant mothers getting prenatal care. Vaccination rates in Brazil exceed 95% and primary school enrollment is near universal. Originally derided, and still criticized by some in Brazil as a handout program for the poor, Bolsa Familia is nevertheless being replicated worldwide.

But a powerful coterie of Brazil’s political leaders believe it’s not enough. Cash transfers alleviate the conditions of poverty, but do not change its trajectory.

That’s where Criança Feliz comes in. The program is adapted from UNICEF and the World Health Organization’s Care for Child Development parent coaching program. Trained social workers visit pregnant women every month and new parents once a week for the hrst three years of a child’s life. Sessions last about an hour. The goal is to not to play with the baby or train the parent, but to help parents have a more loving relationship with their children. The program costs $20 per child per month. The ministry of social development allocated $100 million in 2017 and $200 million in 2018.

Cesar Victoria, an epidemiology professor at the Federal University of Pelotas in Brazil, will conduct a three year randomized control trial comparing kids in the program to kids who are not, on measures of cognition, attachment, and motor development. Caregivers will be evaluated to see what they have learned about stimulation and play.

Criança Feliz neither pities poverty nor romanticizes it. It recognizes that low income people often lack information about how to raise their children and offers that information up, allowing parents to do what they will with it. “It’s one thing to say ‘read to your baby twice a day,”’ says Sanderson. “It’s another thing to say, ‘when your baby hears your voice, there are little sparks firing in his brain that are helping him get ready to learn.’”

Of course, it’s a delicate balance between respecting the right of a family to raise their children the way they see fit and offering information and evidence that could help the child and the family. “You’re in their home, you can’t interfere,” says Teresa Surrita, mayor of Boa Vista. “But you are there to change their mindset.”

Liticia Lopes da Silva 23, a home visitor from Arujé, outside Sao Paulo, says that the initial Visits with families can be hard. “They don’t understand the importance of stimulation and they are resistant to the idea of playing with children,” she says. “They are raised a different way, their parents did not have this interaction with them.” The issue is not just that some mothers don’t play with their babies; some barely look at them. Others treat the visitors as nannies, leaving them to play with the child, thus thwarting the very purpose of the visit, the interaction between parent and child.

But after a few weeks of watching a social worker sit on the floor, playing with the child, and talking with her about the baby’s development, the mothers sometimes join in. “It’s amazing to see the families evolve,” says one home visitor in Arujé. “Three to four months after, you see the difference in how the mother plays with the child. In a different way, the whole family gets involved. Fathers often get involved and many families start to ask the visitors to come more often, although the visitors cannot oblige.

When a home visitor named Sissi Elisabeth Gimenes visits a family in Aruié, she brings a color wheel painted onto a piece of recycled cardboard, along with painted clothespins. She asks Agatha, age three, to put a brown clip on the brown color.

Agatha doesn’t know her colors and gets very shy. Sissi encourages Agatha while chatting with her mother, Alda Ferreira, about how play beneflts brain development. She quietly models how to use encouragement and praise, praising Agatha for finding white, ”the color of clouds”, as the girl slowly gets more confident and gets off her mother’s lap to play.

The activity is intentional. The clips hone Agatha’s fine motor skills as well as her cognitive ones; the interaction with her mother helps create the synaptic connections that allow her brain to grow and pave the way to more effective learning later on. Alda tells us her daughter knows many things that her older daughter did not at the same age.

Agatha

The process changes the social workers as well. One social worker, who has a three year old herself, says that as parents, we think we know everything. “But I knew nothing.” In Aruja, where the home visitors are all psychology students at the local university, working with the program as part-time interns, many admitted to being shocked at seeing the reality of what they’d been taught in the classroom. Poverty looks different off the page. “We are changing because we are out of the bubble,” said one. “Theory is very shallow.”

As we leave Campero’s house, I ask Miranda what she thought of the visit. She too starts to cry. “Gabriella recognizes the program is making a difference in her life,” she says, embarrassed and surprised at her own emotions. Campero had told Miranda a few weeks earlier that she was worried because the baby was not moving. Miranda suggested that Campero try singing to the child in her womb; the baby started to move.

The man who made it happen

In 2003, as secretary of health in Rio Grande do Sul, Terra created Programa Primeira Infancia Melhor (the Better Early Childhood Development Program, or PIM), a home visiting program based on Educa tu Hijo, a very successful case study from Cuba. Results have been mixed, but Terra saw the impact it had on families and communities. He set his sights on expanding the program nationally.

One of the most persuasive arguments for the program, he knew, was the science. But he had to build votes for that science. In 2011, he started lobbying everyone he could to try and get financial backing from congress to fund a week-long course that he helped create at Harvard University’s Center for the Developing Child. He thought if lawmakers, who would be attracted to the prestige of a course at Harvard, could learn from the neuroscientists and physicians there, they might also become advocates for the policy.

“Anybody in the corridor he sees, it’s a hug, it’s a tap on the chest, and then it’s early childhood development,” says Mary Young, director of the Center for Child Development at the China Development Research Foundation and an advisor to Criança Feliz. “He’s got the will and the skill.”

One convert, Michel Temer, who was vice president from 2011 and became president in 2016 when his boss was impeached, tapped Terra to be minister of social development. Soon after, Criança Feliz was born. But trying to get Terra to talk about legislation can be a challenge. What he wants to talk about are neurons, synapses, and working memory. Did I know that one million new neural connections are formed every second in the first few years of life?

And that those neural connections are key to forming memories?

“The number of connections depends on the stimuli of the environment,” he says. And the environment of poverty is relentlessly unkind to the stimuli available to children.

Attachment, he explains, is key, not just psychologically, but neurobiologically. “If a child feels emotionally safe and secure and attached they explore the world in a better way. The safer they feel, the safer their base, the faster they learn,” he says.

The first 1,000 days

Over the past 20 years, scientists have focused on the importance of the first 1,000 days of life. Brains build themselves, starting with basic connections and moving to more complex ones. Like a house, the better the foundation of basic connections, the more complex are the ones that can be built on top. In an infant’s earliest days, it’s not flashcards that create their brains, but relationships, via an interactive process that scientists call “serve and return.” When an infant or young child babbles, looks at an adult, or cries, and the adult responds with an affectionate gaze, words, or hugs, neural connections are created in the child’s brain that allow them to later develop critical tools like self-control and communication.

If kids do not experience stimulation and nurturing care, or if they face repeated neglect or abuse, the neural networks do not organize well. And that, says Charles Nelson, a pediatrics professor at Harvard Medical School, can affect the immune system, the cardiovascular system, the metabolic system, and even alter the physical structure of the brain. “Children who experience profound neglect early in life, if you don’t reverse that by the age of two, the chance they will end up with poor development outcomes is high,” he says.

The strongest buffer to protect against that? A parent, or caring adult.

The case for early childhood as policy was elevated by Nobel Prize winning economist James Heckman. As founder of the Center for the Economics of Human Development at the University of Chicago, he demonstrated the economic case for why the best investment a policymaker can make is in the earliest years of childhood, because that’s when intervention has the highest payoffs.

“The highest rate of return in early childhood development comes from investing as early as possible, from birth through age five, in disadvantaged families,” Heckman said in 2012. His work showed that every dollar invested in a child over those years delivers a 13% return on investment every year. “Starting at age three or four is too little too late, as it fails to recognize that skills beget skills in a complementary and dynamic way,” he said.

More than 506 Brazilian legislators, judges, mayors, state politicians and and prosecutors have attended the Harvard course that Terra helped set up. There, Jack Shonkoff, a pediatrician and professor, explains what infants need to thrive, what toxic stress does to a child and how to build resilience. The attendees are put in groups, maybe a state senator from one state with council members from municipalities in the same state, to spend the week on a project; in the next two-and-a-half months, they finish it with the help of a technical facilitator.

”It’s a little facilitation and a little manipulation,” says Eduardo Queiroz, outgoing head of the Fundaeéo Maria Cecilia Souto Vidigal, a foundation which has played an integral role in supporting and shepherding Criança Feliz. “We create a community.”

It costs $8,800 to attend the program. Some pay their own way. Congress pays for lawmakers to go, and the Fundagéo Maria Cecilia Souto Vidigal funds between 10 and 12 scholarships a year. The fellowship does not require the participants to do anything with their knowledge. But many have. Surrita, who is in her fifth term as mayor of Boa Vista, focused her early governing efforts on working with teens, tackling drugs and gangs as a way to help them. After her week at Harvard, she changed her approach, deciding to make Boa Vista the “early childhood development capital of Brazil.” Investing in young children, she argues, will mean not so many problems with teens:

”After taking this course Harvard on the ECD I realized how important it would be for us to work with the kids from pregnancy up to 6 years old that to develop them mentally and cognitively and that way I realized that it would be possible for us to improve the performance of the teenagers lives by working on them when they’re kids.”

Obstacles and opportunities

Criança Feliz faces two significant threats: the prospect of being shut down, and the challenges created by its own ambition.

Although the Legal Framework for Early Childhood Development, passed in 2016, underpins Criança Feliz, it currently exists as a decree of the president. Of the last three presidents, one is in jail, one was impeached and the current one, Temer, faces criminal charges. With approval ratings of around 3%, Temer has decided not to run again, and the program’s supporters are worried that whoever wins the election will dismantle what the previous government has done (a common practice in Brazil). “We are concerned every day because the program is ongoing and we don’t know if the [next] president will support it,” says Ilnara Trajano, the state coordinator from Roirama state.

Mederios and Terra say the solution to avoiding political death is to create a law that will automatically fund Criança Feliz at the state level, rather than relying on presidential support. Terra, who exudes confidence and optimism, is sure such a law can be passed before the October date set for presidential elections. Others, including Harasawa, are not so sanguine. “We are in a race against time,” she says. She is working around the clock to build support one municipality at a time. She worries that not everyone thinks the government should play a role in parenting. “We are not trying to replace the family,” she says. “We are trying to support it.”

Beyond its political future, the program itself faces a host of issues. In many places, there aren’t enough skilled workers to act as home visitors. There’s also the fraught logistics of getting around. In Careiro da Varzea, in Amazonas state, home visitors often travel five hours, by foot, to reach pregnant women and young children; they are tired when they arrive. In Arujé, seven home visitors share one car to visit 200 families, or 30 visits each, per week. Internet services can be terrible, and wild, dogs often chase the social workers.

The visitors are trained in a curriculum that tells them which materials to use, what to teach and when, and the research that underpins the guidance they give to mothers. But they need more training, and the curriculum does not always prepare them for the poverty and distress they see. Some mothers want to give up their babies; they did not want them in the first place.

Many suffer from depression. The social workers are trained to support nurturing care, but they are not mental health experts. Inevitably, turnover is high.

The evidence for the value of home visiting at scale is at once highly compelling and frustratingly imprecise. Consider the case of Colombia: From 2009 to 2011, researchers there studied 1,419 children between the ages of 12 to 24 months to see whether coaching their mothers on interactions with their babies could help the children’s development. After 18 months, the researchers found a host of benefits. The children whose mothers had received coaching got smarter. Their language skills improved, and their home environments were judged to be more stimulating. But when researchers went back two years later, they found the children, now about five years old, had not maintained those benetits. “Two years after the intervention ended, we found no effects on children’s cognition, language, school readiness, executive functioning, or behavioral development,” the study reported. (Criança Feliz run for a longer period of time, however.)

Governments face notoriously hard choices about where to invest their money. “Early childhood development is a really valuable investment,” says Dave Evans, an economist at the World Bank. “But so is primary education and the quality of primary education, and if you spend a dollar in one place, it’s a dollar you aren’t spending in another place.”

Samuel, Keith, and Giliane

One of the Virtues of a home visiting program, compared to say, building childcare centers, is that social workers can see what is happening inside a home: signs of domestic violence, other children in need, a mother’s depression, a father’s unemployment. They can help with kids like Samuel, who was born with cerebral palsy.

At two-and-a-half years old, Samuel loves his ball, and shrieks with delight when he is presented with a truck. He can’t stop smiling at his mother, Giliane de Almedida Trindade Dorea. She and social worker Keith Mayara Ribeiro da Silva, gather around him to talk and play.

“Where is the dog? Yes! That’s the dog. Very good Samuel!” says da Silva.

The two encourage Samuel to try and stand up. He struggles. “Get up, use your legs,” says Dorea. “You are lazy. Be strong!”

Samuel ignores the women’s requests. He wants to play. They shift gears. “Where is the ball?” da Silva asks. He grabs it and plays. “He’s very smart!” she says. She and Dorea are trying to get Samuel to use one hand, which cannot open, to play with the ball and then the truck. They work together for 15 minutes to find a way to get him to use his weak hand, but he just wants to play with his dominant hand.

Dorea adores her son and plays with him patiently. But it has been hard, she says. When da Silva started to visit, Samuel could not sit up, he was quite shy and often cried. Da Silva has helped the family access the services and care that Samuel needs: a physiotherapist, an occupational therapist, an acupuncturist, and a doctor to check his hearing. These are services the government will provide, but finding them and organizing the appointments is time consuming and can be overwhelming.

Dorea says Samuel has changed since Keith has been coming. “His interaction with people, he’s totally different. He was so shy.” In fact, she says the whole family has benefited. Her older daughter also knows how to play with Samuel and loves to help. She appreciates the support. Raising a child with a disability is hard work. “The visitor is a like a friend who comes every week not just for fun but also to share my concerns,” she says. Her biggest complaint about the program? “It’s too short.”

Will it survive?

There is a maxim in investing that you have to survive short-run volatility to get to the long run, you can’t make money if you don’t have any. Criança Feliz faces the same problem. Child development takes time. It is not a jobs program or a construction project, which voters can see.

The benefits can take years to show up, and politicians have never been known for their long-term thinking.

Alberto Beltrame, the current minister of social development, is a believer. Start early and you shape character, transforming the child into a better young adult and, eventually, creating an improved workforce, he says. You reduce violence and crime. He agrees that Bolsa Familia alone is not enough. It does not promote autonomy, or break the cycle of poverty. What is needed is a two-pronged approach: In the short term, promote training, microcredit, and entrepreneurialism to create jobs. For the medium and long term, Criança Feliz.

“We have a huge array of benefits that we are going to gain with this one program, and the cost is very, very low compared to others,” he says.

In every home we visited, mothers said they loved the support, be it information, toys, or more often, company to share their challenges and triumphs. Priscila Soares da Silva has three children, including six month old Allyce, and another on the way. With Allyce, she says, she has changed her approach to parenting, setting time aside to play every day now. “You raise children your way,” she explains cooing over Allyce. “When you see there are other visions, you see the way you did it was not so right.” She is also refreshingly honest about something all parents know: We do it better when someone is watching. “There are things we know, but we are lazy. When she comes, we are better.”

When I quietly ask her teenage daughter, who is lingering in the corner, what she thinks of the visits, she answers immediately: “She’s so much more patient,” she says of her mother. Her own takeaway: Parenting is hard, and she does not want to do it anytime soon. Priscila smiles at this, agreeing she started too soon, and noting the benefits of the program have extended beyond Allyce and the baby she will soon have. “The program got the family closer.”

Evans, from the World Bank, is watching the program closely. “I see Criança Feliz as a big, bold, gamble about which I am optimistic,” he says. “But I think the measurement and the evaluation is crucial to see if it is a model that other countries want to echo.”

If it survives the near term political turbulence, Beltrame says it can go way beyond the poor to beneiit everyone. “We are trying to make the Brazilian people realize, independent from their level of income, that stimulating children from pregnancy through the first 1,000 days of life is important,” he says. Better young people equal healthier and better adults, who are more emotionally connected and can be better citizens.

With Crianea Feliz, Beltrame says, we have the “possibility of having a new destiny and future for each one of these children.”

The Lancet

Advancing Early Childhood Development: from Science to Scale

An Executive Summary for The Lancet’s Series

Overview of the Series

The 2016 Lancet Early Childhood Development Series highlights early childhood development at a time when it has been universally endorsed in the 2030 Sustainable Development Goals.” This Series considers new scientific evidence for interventions, building on the findings and recommendations of previous Lancet Series on child development (2007, 2011), and proposes pathways for implementation of early childhood development at scale.

The Series emphasises “nurturing care”, especially of children below three years of age, and multi-sectoral interventions starting with health, which can have wide reach to families and young children through health and nutrition.

Key messages from the Series

The burden and cost of inactian is high.

A staggering 43 percent of children under five years of age, an estimated 250 million, living in low and middle income countries are at risk of suboptimal development due to poverty and stunting. The burden is currently underestimated because risks to health and wellbeing go beyond these two factors. A poor start in life can lead to poor health, nutrition, and inadequate learning, resulting in low adult earnings as well as social tensions. Negative consequences impact not only present but also future generations. Because of this poor start, affected individuals are estimated to suffer a loss of about a quarter of average adult income per year while countries may forfeit up to twice their current GDP expenditures on health and education.

– Young children need nurturing care from the start.

Development begins at conception. Scientific evidence indicates that early childhood is not only a period of special sensitivity to risk factors, but also a critical time when the benefits of early interventions are amplified and the negative effects of risk can be reduced. The most formative experiences of young children come from nurturing care received from parents, other family members, caregivers, and community based services. Nurturing care is characterised by a stable environment that promotes children’s health and nutrition, protects children from threats, and gives them opportunies for early learning, through affectionate interactions and relationships. Benefits of such care are life long, and include improved health, wellbeing, and ability to learn and earn. Families need support to provide nurturing care for young children, including material and financial resources, national policies such as paid parental leave and provision of population based services in a range of sectors, includlng health, nutrition, education, and child and social protection.

We must deliver multi-sector interventions, with health as a starting point for reaching the youngst children.

Interventions, including support for families to provide nurturing care and solving difficulties when they occur, target multiple risks to development, and can be integrated into existing maternal and child health services. Services should be two pronged, considering the needs of the child as well as the primary caregiver, and include both (are for child development as well as maternal and family health and wellbeing. This affordable approach is an important entry point for multi-sectoral collaborations that support families and reach very young children. Essential among these are nutrition, to support growth and health, child protection, for violence prevention and family support. social protection, for family financial stability and capacity to access services; and education, for quality early learning opportunities.

– We must strengthen government leadership, to scale up what works.

It is possible to scale up projects to nationwide programmes that are effective and sustainable, as indicated by four country case studies in diverse world regions. However, government leadership and political prioritisation are prerequisites. Governments may choose different pathways for achievmg early childhood development goals and targets, from introducing tansformative government wide initiatives to progressively enhancing existing services. Services and interventions to support early childhood development are essential to ensuring that everyone reaches their potential over their life course and into the next generation, the vision that is core to the Sustainable Development Goals.

Risks to early childhood development remain high

Updated definitions of stunting and extreme poverty and improved source data were used to re-estimate the number of children under 5 years in low and middle income countries who are at risk of not reaching their developmental potential. Between 2004 and 2010, this number declined from 279 million (51 percent of children in 2004) to 249 million (43 percent of chiidren in 2010), with the highest prevalence in sub Saharan Africa (70 percent in 2004 and 66 percent in 2010).” An illustrative analysis from 15 countries with available Multiple indicator Cluster Surveys in 2010 or 2011 demonstrates the implications of additional risks to chiidren’s development beyond poverty and stunting, induding low maternal schooling (completed primary school) and child physical abuse by either parent or by caregivers (severe punishment of children aged 2 to 5 years, such as hitting a child as hard as possible, or with a belt or stick). Estimates of children at risk increase dramatically when low maternal schooling and this kind of physmal abuse are added, from 62.7 percent (exposed to risks of stunting or extreme poverty), to 754 percent, with large disparities among sub national social and economic groups.

Global commitments to early childhood development are growing

Since 2000, the rapid increase in publications on the topic of early childhood development surpassed the general trend for health sciences publications. However, only a few of the publications reported on interventions.

The numbers of countries with national multi sectoral early childhood development policies increased from seven in 2000 to 68 in 2014, of which 45 percent were low and middle income countries. There has also been substantial investment in early childhood development during that time period. For example, since 2000 the Inter American Development Bank has approved more than 150 projects for over US$17 billion. From 2000 to 2013, the World Bank Invested $3.3 billion in 273 projects, primarily through health, nutrition, and population programmes. Still, investment falls short of the need and the impact of available interventions.

Early childhood development from a life course perspective

Childhood development is a maturational process resulting in an ordered progression of perceptual, motor, cognitive, language, socio emotional, and selfregulation skills. Thus, the acquisition of skills through the life cycle builds on the foundational capacities established in early childhood.

Multiple factors influence the acquisition of competences and skills, including health, nutrition. security and safety, responsive caregiving, and early learning (Figure 1), Each are necessary for nurtunng care. Nurturing care reduces the detrimental effects of disadvantage on brain snucture and function which, in turn, improves children’s health, growth, and development.

Interventions, including nurturing care, benefit early childhood development

Interventions identified by reviews between 2011 and 2015, and country policies shown to have significant benefits for childhood development, are summarised and organised into packages in Figure 2. Many of the health and nutrition interventions have additional beneflts for improved child survival and growth, as well as reduced morbidnes and disabilities.

Family support and strengthening package

Three elements of family strengthening increase the likelihood that families are able to provide nurturing care for their children: access to quality services (eg, antenatal care, immunisation, nutrition), skills building (29, nurturing care and reduction of harsh discipline); and support (eg, social protection, safety networks, and family support policies)

Caring for the caregiver package

This two generation package emphasises care and protection of parents’ physical and mental health and wellbeing, while enhancing caregivers’ capacnty to provide nurturing care to their child.

Early learning and protection package

This set of interventions integrates the support of young children with parental support and the facilitation of teachers’ and caregivers’ ability to create a nurturing environment in day care and early childhood centres. The emphasis is on quality and family support through parental empowerment, guidance on nutrition and care, and child protection.

Parent support pvogrammes

Parent support programmes that promote nurturing care, particularly those employing several behaviour change techniques, can substantially augment the positive effects on early childhood development outcomes of basic health and nutrition, education, and protection interventions. In contrast, maltreatment during childhood is associated with reduced volume in brain regions involved in learning and memory. Children who receive inadequate care, especially in the first 24 months of life, and often from mothers who themselves were neglected or abused, are more sensitive to the effects of stress and display more behavioural problems than do children who receive nurtunng care.

Multi sectoral interventions improve childhood development

The effectiveness of interventions could be improved by taking into consideration the major insights gained over the past decade about how human development is affected across generations by complex and multi faceted experiences. Sectoral interventions combined with elements of nurturing care and protection, can boost the effect on child outcomes. This approach encourages interventions directed at the family as a unit rather than the child alone.

Learning from early childhood development programmes at scale

An analysis of country programmes illustrates the importance of political prioritisation, legislation, and policy, and the use of existing systems and financing to scale up. These programs focus on addressing poverty, inequality, and social exclusion, starting early. Scaledup early childhood development programmes most often have a vision of comprehensive and integrated services for children and families; have been founded by statute or other formally communicated government strategy; have been funded by government; and have been led by a government department or agency working collaboratively with other departments and civil society organisations.

Framework for action

To promote health and wellbeing across the life course at scale requires interventions provided through several sectors, and a supportive environment of policies, cross sectoral coordination, and financing (Figure 3).

At the heart of this intervention framework is the nurturing care of young children, provided by parents, families, and other caregivers Particularly successful are parent support programmes to promote nurturing care, among which the most widely implemented in low and middle income country settings are the WHOIUNICEF Care for Chiid Development and Reach Up and Learn, a parenting programme tested in trials in Jamaica over the past 20 years and now expanding to other regions.

Affordability of early childhood development interventions

To assess the affordability of including interventions to promote early childhood development in existing health and nutrition services, this paper estimates the additional costs of incorporating two interventions aimed at supporting nurturing care of children into the services identified in the Global Investment Framework for Women’s and Children’s Health.“ The First intervention is based on Care for Child Development and the second on support for maternal depression, because it bolsters nurturing care. The estimated average additional investment needed is half a dollar per capita in the year 2030, ranging from US$01 in low income countries to US$07 in upper middle income countries This represents an additional 10 percent over published estimates for a comprehensive set of women’s and children’s health and nutrition services.

The cost of inaction

At an individual level, the loss of average adult income per year for the 43 percent of children at risk of not reaching their developmental potential is likely to be 26 percent, exerting a strong downward economic pull and trapping families in poverty. At a societal level, the cost of inaction for not improving stunting to a prevalence of 15 percent or less and not addressing developmental delays through preschools and home visits is several times more than what some countries currently expend on health or education respectively. The cost of inaction for not improving childhood development through preschool and home visits rises sharply in settings with fewer preschool services, as well as in settings with a higher prevalence of children at risk of poor development.

Pathway to scale

Action 1: Expand political will and funding through advocacy for the Sustainable Development Goals (SDGs)

Under the broader SDG umbrella, investing in early childhood development has become not only an aim in itself, but a requisite for achieving many other SDGs (eg, SDGs 1, 5, 10, 16, and 17). For example, SDG Target 4.2 under the learning goal, calling for universal access to quality eady childhood development, care, and pre-primary education, provides unprecedented opportunity to scale up early childhood development services,

Action 2: Create a policy environment that supports nurturing care of young children

Laws and policies can improve childhood development by increasing access to and quality of health and other services, as well as money and time for parents to provide nurturing care for their young children. Five transformative policies for which there is robust global data on levels, duration, coutry coverage, and progress achieved in the past two decades include: 1) paid parental leave for new mothers and fathers; 2) breastfeeding breaks at work, 3) paid leave for parents to care for sick children; 4) income support through a minimum wage; and 5) tuition free pre-primary education. Governments, with the technical and funding assistance of development partners, must also ramp up efforts to analyse their situation, identify gaps and priority areas for intervention, and develop sustainable and costed action plans to promote early childhood development at scale.

Action 3: Build capacity to promote early child development through multi sectoral coordination

Many efforts to promote early childhood development are dependent on non governmental services, which are frequently limited in scope and inequitable in coverage. Interventions are highly dependent on skilled human resources and, unless built on existing service systems such as health, education, social and child protection, face severe supply side constraints. This is illustrated by lessons learned from the scale up between 2000 and 2009 of more than 120 cash transfer programmes in low and middle income countries

We identified multiple examples in health and nutrition services into which interventions to promote nurturing care and improve childhood developmental outcomes have been feasibly and effectively incorporated. Opportunities also exist in other sectors. which is important for the continuity of support from early childhood into schooling. For example, in the education sector, childhood development can be supported through a variety of early learning opportunities, including the prvisiin of child day care services, preschool, and parent education. Interventions can also be provided through child and social protection services, including cash transfer programmes. Thus, the integration of early childhood development interventions into existing service delivery platforms, starting with health, is an effective and efficient way to reach large numbers of families and children.

Action 4: Ensure accountability for early child development services, increase research, and foster global and regional leadership and action

Ensuring the inclusion of a core set of early childhood development indicators, which go beyond access and process and hold stakeholders accountable for childhood development in the global metrics for the SDGs, is of paramount importance. Research that links detailed longitudinal data on policies and programmes with outcomes, allowing causal modelling, is essential.

Conclusion

Strong biological, psychosocial, and economic arguments exist for intervening as early as possible, starting from and even before conception, to promote, protect, and support children’s development. An emphasis on the first years of life is articulated within a life course perspective. High quality care in families, child day care services, and preschools during the earliest years needs to be followed by high quallty schooling and services into adolescence in order to capitalise on interdependence between investments made in the successive stages of the life cycle.

Multi sectoral interventions, with health services as an entry point, are particularly well-placed to reach children early with services that support families to deliver nurturing care and promote, protect, and support early childhood development, Interventions to promote nurturing care can feasibly build on existing health and nutrition services at only a limited additional cost. Coordination with education is needed to promote learning, and with social and child protection, to reach the most vulnerable population:

Evidence consolidated in this series points to effective interventuons and delivery approaches at a scale that was not envisaged before, During the next fifteen years. world leaders have a unique opportunity to invest in the early years for long-term individual and societal gains and achievement of the SDGs. All sectors must play their part in supporting families to prowde nurturing care for children.

However, the time has come for the health sector to expand its vision of health beyond prevention and treatment of disease to include the promotion of nurturing care for young children as a critical factor In the realisation of the human potential of all people.

A groundbreaking study offers undeniable proof that the fight against inequality starts with moms

Jenny Anderson

Children born into poverty start at a big disadvantage. To thrive, they need food, shelter, and health care. But a growing body of evidence shows there are other ways to help close the vast gap in development between poor kids and their wealthier peers: singing, talking, and playing with them.

If this sounds obvious or inconsequential, it’s not. Dealing with the stress of poverty makes it hard for many parents to establish critical bonds with their babies, bonds that lay the foundations for learning, emotional regulation, and relationships. Poor parents are “focused on survival and illness and food and health care,” says Sally Grantham-McGregor, an emeritus professor of international child health at University College London and University of the West Indies. “There’s no time to play with children, it seems frivolous.”

But playing with babies turns out to be anything but frivolous. Grantham-McGregor and her colleagues have spent more than 40 years pioneering research which showed just how much supporting mothers in the earliest days of a child’s life can directly benefit that child. In the 1970s, Grantham-McGregor and Christine Powell, from the University of the West Indies, began a research project aimed at helping young children from poor backgrounds and their moms in Kingston, Jamaica. They designed programs that sent doctors and nurses to visit mothers every week in their homes for two years, bringing toys and books that would help parents become better teachers to their babies and to increase stimulation and play.

The resulting studies found that children whose mothers received coaching made significant developmental gains, and not just in the short term. Twenty-two years later, the kids from one group who had received those home visits as young children not only had higher scores on tests of reading, math, and general knowledge, they had stayed in school longer. They were less likely to exhibit violent behavior, less likely to experience depression, and had better social skills. They also earned 25% more on average than a control group of kids whose mothers had not received the coaching.

The highly influential Jamaica studies have influenced the way many countries think about investing in early childhood development. Brazil, Guatemala, Zimbabwe, Bolivia, Peru, Colombia, Bangladesh, and India are all trying parent coaching programs, many based on the Jamaica model. It’s easy to see why some countries are embracing such an approach. After all, it’s in every country’s best interest to ensure that its most disadvantaged citizens get the support they need to live productive, fullilling lives.

“If we want to attack poverty, the place to start is very early in life,” says Paul Gertler, an economist who studied the long-term effects of the Jamaica program. Research shows that poverty affects a young child’s development on multiple levels, from their cognitive and educational performance to their physical health and social and emotional development. Compared to the cost of unemployment benefits or other social safety net programs, “getting it right to start with is cheaper.”

To tackle the lasting effects that inequality can have on a child’s life, we have to start early. The work of Grantham-McGregor and her team in Jamaica offers some of the best evidence we have about what governments can do to support families in an effort to close the intractable gap between rich and poor children everywhere.

The Jamaica experiments

Much as caregivers in poor countries typically want their children to succeed, it’s not necessarily obvious that a key way to do this is to talk and sing to babies, respond to them when they cry, and find other ways to engage them with the world. Consider a 2012 nationally representative survey in Brazil, which asked mothers, 52% of whom were college educated, what things were most important for the development of their children up to three years of age: only 19% mentioned playing and walking, 18% said receiving attention from adults, and 12% picked receiving affection.

The Jamaica studies showed how much these things matter. Through randomized controlled trials supporting poor, often uneducated mothers, the programs dramatically improved children’s development. (The effect sizes have been described as “astounding.”) It expanded the scope of helping poor children from health and nutrition to stimulation and responsiveness.

While the earliest studies used health professionals as home visitors and relatively expensive toys and materials, Grantham-McGregor and Powell quickly changed the program’s model to save money, using community health workers instead of doctors and nurses and homemade toys. Over the course of seven studies, they also experimented with different levels of frequency for the home visits and worked with babies experiencing different kinds of deprivation, including severely malnourished infants and children who had been born at a low birth weight.

They found that the effects of early intervention were both long-lasting and complex. One study tracked 129 stunted children, that is, babies smaller than well nourished children of the same age and gender, who show persistent developmental delays as they grow up. Researchers followed a group of children and mothers that received weekly home visits for two years, as well as other groups of children, including a control group. The study then tracked the children’s development for up to 22 years.

The beneflts of the intervention seemed to vary as the children grew up. After two years, the infants in the visiting group showed significant developmental gains. They actually caught up to kids who were not stunted, an enormous victory.

Over time, however, some of the effects seem to fade or fluctuate. At 7 to 8 years of age, the mean IQ from the intervention group was no higher than that of the control group. By age 11 to 12, the children who had been in the home visiting group had signincantly higher IQs than the control group, but showed no significant improvements in behavior or school achievement.

Then, when researchers tested the intervention group again at age 22, they found a battery of benefits, from higher income to better social skills and less violent tendencies.

Many researchers might have given up when the effects of the early intervention programs seemed to fade. But the benefits resurfaced with a bang, proving that programs that coach mothers can bring about lasting, significant, long-term results. In 2016, Grantham-McGregor and Smith published research in the Journal of Applied Research on Children exploring 12 published trials in five different countries, all of which were based on the original findings of the Jamaica program.

“Jamaica was so important because it shows us the potential of what can be done, the importance of stimulation, and that impacts can be long lasting,” says Amanda Devercelli, global lead for early childhood development at the World Bank. The challenge lay in taking Jamaica’s small program with big effects and making it accessible to the millions of poor families who need it.

The brain science behind nurturing care

In the years since the Jamaica studies, the science underscoring the critical opportunities and risks of early childhood has exploded. Neuroscience revealed the incredible plasticity of the early brain, showing that the foundations for learning opportunities and risks of early childhood has exploded.

Neuroscience shows that the foundations for learning as well as children’s social, emotional, and moral development start as early as pregnancy, and spike in a baby’s earliest years. Like a house, children’s brains need strong foundations. Their brains cannot fully develop without responsive caregiving; people who help them form deep and trusting attachments; and stimulation. Stress during a child’s early years, whether from poverty, malnutrition, neglect, or abuse, can negatively affect their nervous system in ways that can create lifelong problems with learning, behavior, and physical and mental health.

A foundational tenet of nurturing care is the importance of serve and return, which refers to adults’ responses to a child’s attempts at communication, from crying and babbling to gazing and smiling. According to the National Scientific Council on the Developing Child and the Center for the Developing Child at Harvard, “The interactive influences of genes and experience literally shape the architecture of the developing brain, and the active ingredient is the ‘serve and return’ nature of children’s engagement in relationships with their parents and other caregivers in their family or community.”

The neurobiology of early childhood presents a challenge to policymakers. Until fairly recently, policy makers focused their dollars and attention for children on education, usually starting around age five.

But five years old is too late. Research shows that developmental deficits between richer and poorer children can show up in kids as young as seven months. By the time children are in school, the gaps between advantaged children and disadvantaged ones are already enormous. School tends to exacerbate those rifts.

“It’s fairy well established that how well a child has developed cognitively, language development, socially, emotionally, when they enter school will determine to a large extent how well they do in school, and that will have repercussions in adulthood including the intergenerational cycle of poverty,” says Grantham-McGregor. This means the bigger a developmental deficit is early on, the harder it is for poor kids to catch up.

Grantham-McGregor is excited about the developments in neuroscience. But she’s emphatic that it’s already well established that mothers from disadvantaged homes benefit from this kind of help. “The brain research is exciting and it’s helpful because people pay attention,” she said. “It’s good for advocacy, but we were doing these programs before this data came out. And we’re still doing them.”

Expanding the lessons of Jamaica

Economists have joined the neuroscientists, arguing with data, that investing in early childhood is the most cost-effective way to affect long-term outcomes like education and employment.

James Heckman runs the Center for the Economics of Human Development at the University of Chicago, and won the Nobel prize in 2000 for his work in microeconometrics. He has since focused on applying his work to early childhood, including analyzing of the Jamaica research. He estimates that the best investment any policymaker can make is in the earliest years of childhood, because these interventions have the highest payoffs.

“The highest rate of return in early childhood development comes from investing as early as possible, from birth through age five, in disadvantaged families,” Heckman said in 2012. “Starting at age three or four is too little too late, as it fails to recognize that skills beget skills in a complementary and dynamic way.”

The key, it seems, is ensuring that families have the support and tools they need to bond with young children and provide them with engaging environments. “We know from developmental science that families are the biggest builders of skills and abilities in their children in the earliest years,” Heckman tells Quartz. “Jamaica shows that simple but effective parental education can produce better child outcomes.”

Jamaica inspired programs now exist all over the world, as do hundreds of other parenting programs. The biggest issue they face? How to get the strongest outcomes in the most affordable way. In a sense, Jamaica set the bar uncomfortably high for this, due to its small size and the fact that the home visitors were highly trained, and the coaching quite intensive.

“Our challenge now is to take what we learned from Jamaica and design programs that are affordable and feasible in many diverse low-income settings,” says Devercelli from the World Bank.

One study in Colombia looked at whether a more affordable, and scalable, version of the Jamaica program could produce the same effects. It used a large sample, studying 1,420 children aged 12-24 months and their primary caregivers in 96 municipalities, and tied the implementation of the home visits to an existing social protection program, conditional cash transfers. The results showed positive and significant effects on cognition and language, though smaller than the effects in Jamaica, as would be expected.

Meanwhile, in 2012, the Peruvian government implemented Cuna Mas, a home-visiting program based on many of the materials and foundations used in Jamaica and perhaps the best example of Jamaica operating at scale. The program has reached over 90,000 Peruvian families. Early research shows positive and significant effects on children’s cognition and language, as well as parenting practices, although the effects are smaller than in either Jamaica or Colombia.

“As you scale, the impacts are smaller,” says Marta Rubio Codina, a senior economist at the Inter-American Development Bank. Reducing costs to make the programs more affordable for governments means that quality can suffer. The goal, she says, is to figure out how to minimize those compromises. “My bet is that we have to invest in the workforce: training the home visitors and training their mentors.”

To help other countries develop and measure their own programs, an international collaboration of academics headed by the Jamaican group at the University of the West Indies developed Reach Up and Learn, a web-package of materials and curriculum and training manuals which are being used in places from Colombia, India, Peru, and Brazil. One Challenge: making sure the curriculum reflects the country’s culture, including local games, rhymes, songs, and stories.

“Adapting to culture is a lot of work,” says Grantham-McGregor. Pretend games taught to parents may need to be adapted, going to the field to work, or spinning wool, depending on common occupations. Local artists also need to redraw pictures to reflect a given culture’s typical housing, landscape, and style of dress, among other things.

Countries are experimenting with other variations on the program. Bangladesh has built a strong body of evidence that Jamaica-type programs are effective. They are experimenting with small groups of mothers visiting health workers in clinics, rather than having workers come to their homes.

As the long-term benefits of such programs materialize, early childhood advocates are urging governments to find more ways to support mothers and families. In 2016, the Lancet published a series of articles on early childhood highlighting the unique opportunity the early years offer to policymakers. Writing for the Lancet, Pia Britto, an adviser to Unicef, wrote that we now know the critical importance of “nurturing care,” which she defines as a set of interrelated concepts around caregiving, ranging from hygiene to stimulation (talking, singing, playing), responsiveness (early bonding, secure attachment, trust, and sensitive communication), and safety (routines and protection from harm).

“The single most powerful context for nurturing care is the immediate home and care settings of young children often provided by mothers, but also by fathers and other family members, as well as by childcare services,” Britto writes. Thanks to the Jamaica experiments, the world has increasingly accepted this fundamental truth: The best way to help poor kids is to start early, and give mothers and families the support they need.

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